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� <br /> � � <br /> . <br /> � r <br /> ��nnesota Poilution Cornpliance inspection Form <br /> Control Agency <br /> 520 Lafayette Road North �sting Subsurface Sewag�T�tmant Systems(SSTS) <br /> St.Paul,MN 55155-4144 DOC Type:Comp0enc8 and EntorCement <br /> Inspection resulb besed on Minnesota PolluMon CoMrol Agency(MPCA) For lacel trecking purposes: <br /> requiremeM�and a�tact�ed fom�—addiUonal local requkemenls may also apPly <br /> Submit compkted fomn to Local Unit of GovammeM(LU(3)and syutem owner <br /> within 16 days <br /> System Status <br /> Systetn 6tatu8 on date(mmlddlyyyyj: 7/8l2012 <br /> �Compliant--Certificate of Compiiance ❑ Noncompliant—Notice of Noncompliance <br /> (VaNd for 3 yeara hwr►report defe,unless shorter llme (Sae Upgrede Requirernents on pege 9.) <br /> Irarrre ouNi�d in Locel Ordinance.) <br /> Rsason{s)for noncompliance(check all applicab/e) <br /> ❑Impacl on Public Heakh(CompBance Component#1)—JmmMent throat to publk health er►d sefety <br /> ❑Oiher Compliance Cond�ions(CompUanoe Cornponent 1tik?)—Imminent threa[to publlc health end safsfy <br /> . ❑Tank Intc9�Y(�P�lance Component 1�2)—Fe�to proted groundwater <br /> ❑Other CompNence Condittons(Compqancre Component#3)—Failing to protect groundwete� <br /> ❑3011 Separation(Complfance Component#4)—FaNing to protect groundwafer <br /> ❑OperaBng permiUmoniioring plen requfremenls(Compliance Componenf#6)—fVonraompllant <br /> . Property tnformation paroel ID#or 3ec/1'wp/Ranas: <br /> Property address: 24fi0 Cou�ty Rd,6 Resaon for Inspectbn: Tranefer of PropertY <br /> Prope�ty owner: Steven BouleY Owner's qhone: 783-4T8-6803 ..._._.._.. <br /> or <br /> Ovmer's represerrtaUve: KathY end J{m Sewicltl-0oldwell Bumett Rapreaentative phorro: 812-270-1001 <br /> Local reguletory authority: Henneain CouMv Regulatoty authority phone: <br /> &ief syst�n deecxlpUon: 2-1260 9aMon tenks and 1-1260 g�on pump tank to e ar�sure ted mound <br /> Commorrts or reaommendatlons: ' <br /> Certificat9on <br /> 1 hereby cert�y fhat all the neceasery/nformefbn hae been peihered b deferrnlne the oompNar�ce atatua of this system.IYo <br /> �terminatbn of hitws sy�m per/ormance has been nor cen be made dua ta unlmown condHlor►s du►fr�g system conshucBon, <br /> pos�ib�e abuse olthe sY�evn.6radequate mak�tenance,orAr�ne waterusege. <br /> Inspector name: Tristan Ende Ce�on raxunber: C8208 <br /> Bueinese name: Ende S Service Llcense number. L2664 <br /> Inapector signature. Phone nurnber: 799-428-4489 <br /> Necessary or Localty Requfred Attachments <br /> ($�Soil bor(ng bgs �SysbmlAs-bullt drawinp ❑F�ne per local orcNnance <br /> ❑Other informatlon(Itay: _ � <br /> www.pca.state.mn.us • 651-296-6300 • 800•657-3864 • T1Y 651-282•6332 or 800-657-3864 • Avaflabte tn alGemsdve formats <br /> Mnq•wwlsts4•3f • 3/16/12 Phge 1 of 3 <br />